Laserfiche WebLink
Facility Na <br />Facility Ad <br />Telephone* <br />Person F I <br />Report: <br />4VENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />I hereby certify under penalty of perjury that all inventory <br />variations for the above mentioned facility were within the <br />allowable limits for this quarter. (No in column 13 of the <br />Inventory Reconciliation Sheet.) <br />Inventory variations exceeded the allowable limits for this <br />quarter. I hereby certify under penalty of perjury that <br />source for the variation was not due to authorized (leak) <br />release. in Column 13 of the Inventory Reconciliation <br />Sheet). <br />List date, tank 1, amount for all variations and the reason <br />for exceeding the allowable limits. <br />Amount <br />-o�4 <br />G,QS La <br />G,45 Lo/ -TD . <br />Ci A5 L -of. �) - <br />Additional dates/amounts shall be continued on a separate <br />sheet of paper and attached. <br />If the source of the variation which exceeded allowable limits <br />was due to a leak, the incident shall be reported to Public <br />Health Services of San Joaquin County Environmental Health <br />Division, within twenty-four (24) hours and an unauthorized <br />release report submitted. <br />The quarterly summary report shall be submitted within fifteen (15) days of <br />the end .of each quarter. Circle appropriate quarter. <br />Quarter 1 - January ------;----->March <br />Quarter 2 - April ----------- >June <br />Quarter 3 - July ------------ >September <br />Quarter 4 - October --------- >December <br />Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />(209) 468-3420 <br />EH 23 019 (10/89) 0 <br />M in W1. <br />WM "Al <br />I hereby certify under penalty of perjury that all inventory <br />variations for the above mentioned facility were within the <br />allowable limits for this quarter. (No in column 13 of the <br />Inventory Reconciliation Sheet.) <br />Inventory variations exceeded the allowable limits for this <br />quarter. I hereby certify under penalty of perjury that <br />source for the variation was not due to authorized (leak) <br />release. in Column 13 of the Inventory Reconciliation <br />Sheet). <br />List date, tank 1, amount for all variations and the reason <br />for exceeding the allowable limits. <br />Amount <br />-o�4 <br />G,QS La <br />G,45 Lo/ -TD . <br />Ci A5 L -of. �) - <br />Additional dates/amounts shall be continued on a separate <br />sheet of paper and attached. <br />If the source of the variation which exceeded allowable limits <br />was due to a leak, the incident shall be reported to Public <br />Health Services of San Joaquin County Environmental Health <br />Division, within twenty-four (24) hours and an unauthorized <br />release report submitted. <br />The quarterly summary report shall be submitted within fifteen (15) days of <br />the end .of each quarter. Circle appropriate quarter. <br />Quarter 1 - January ------;----->March <br />Quarter 2 - April ----------- >June <br />Quarter 3 - July ------------ >September <br />Quarter 4 - October --------- >December <br />Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />(209) 468-3420 <br />EH 23 019 (10/89) 0 <br />